Progesterone: Prevention of Premature Birth & Birth Injuries such as Periventricular Leukomalacia (PVL) & Cerebral Palsy
Preterm labor can cause preterm birth, which can lead to a number of complications, including cerebral palsy, intracranial hemorrhages (brain bleeds), infection, periventricular leukomalacia (PVL), hypoxic ischemic encephalopathy (HIE) and sepsis. Approximately 12 % of all births in the U.S. each year are preterm. The normal course of pregnancy is between 38 and 42 weeks. A baby is preterm or premature when she is born before reaching 39 weeks. These babies are at a higher risk of complications and birth injuries because they have underdeveloped lungs, organs and immune systems.
In order to avoid complications, physicians should make every effort to prevent a preterm birth. Pregnancy should be prolonged until the baby has reached term or close to term, thereby giving the baby time to develop more fully. A promising treatment for the prevention of preterm birth is the administration of vaginal progesterone or progesterone injections or pills. Progesterone supplementation has been shown to significantly reduce the risk of preterm birth in women who have a short cervix and women who have had a previous spontaneous preterm birth.
What Is Progesterone?
Progesterone is a steroid hormone produced in the body that helps a woman become and remain pregnant. In early pregnancy, progesterone helps the uterus grow and keeps it from contracting. If the uterus contracts early in pregnancy, a baby may deliver prematurely and miscarriage may occur. In later pregnancy, progesterone helps the breasts get ready to create milk for the baby, and it helps the lungs work harder to provide oxygen for the growing fetus. Removal of progesterone (either from the ovary or administration of a drug that inhibits progesterone) readily induces abortion before 7 weeks of gestation. When labor occurs – both at term and preterm – it is associated with a functional withdrawal of progesterone activity at the uterus.
Risk Factors for Premature Birth
Factors that put a woman at risk of having a preterm birth include the following:
- A previous preterm birth
- An incompetent or short cervix (when the narrow, tube-like opening to the uterus is 20 millimeters or less before 24 weeks of gestation)
- A pregnancy with more than one bay, such as twins or triplets
- Symptoms of labor, such as early contractions that start to open the cervix
- A ruptured amniotic sac (rupture of the membranes, or ROM and premature ROM (PROM)
- Infections in the mother, such as UTI, BV, GBS and HSV
- Uterine abnormalities
- Kidney disease
- Substance abuse
- Chronic diseases, such as high blood pressure or diabetes
Birth Injuries Caused By Premature Birth
Conditions that can occur when premature birth isn’t prevented or premature babies have mismanaged medical care include the following:
- Intraventricular hemorrhages (IVH – brain bleeds)
- Periventricular leukomalacia. Although PVL can occur in term infants, it is most frequently found in premature babies.
- Hypoxic ischemic encephalopathy. HIE usually occurs in term infants, but sometimes premature babies can develop HIE. HIE usually involves damage to the basal ganglia, cerebral cortex and watershed regions of the brain, but sometimes also includes PVL.
- Neonatal encephalopathy
- Permanent brain damage
- Seizure disorders
- Cerebral palsy (CP)
- Intellectual disabilities
- Developmental delays
- Motor disorders
Short Cervix: Diagnosis and Risk Factors
A short cervix is the strongest predictor of premature birth. It is recommended that all pregnant women have their cervices measured between weeks 19 and 24 of pregnancy. If a pregnant woman has a history of premature birth, the physician should begin carefully monitoring her cervical length with ultrasounds every 2 weeks, from week 15 through week 24 – 26 of pregnancy. A cervix is considered short when it is 25 millimeters or less before week 24. Risk factors for a short cervix include the following:
- D & C procedures (surgeries that scrape the uterine lining)
- Diagnosis of cervical incompetence in a previous pregnancy
- Previous preterm premature rupture of membranes (PPROM)
- A biopsy of the cervix used to remove pre-cancerous cells or for diagnostic purposes (cone biopsy / cervical conization)
- Trauma from a previous childbirth during which the cervix was torn
- Repeated or late-term abortion
- Uterine abnormalities and anomalies
- Exposure to the drug diethylstilbestrol (DES)
Progesterone Treatment to Prevent Premature Birth and Birth Injuries Such as Periventricular Leukomalacia (PVL)
Progesterone therapy works by helping to keep the uterus quiescent, or calm and not contracting, thereby preventing preterm labor. For women who are pregnant with one baby (singleton pregnancy) who have had a previous spontaneous twin or singleton preterm birth, the following is recommended:
- Progesterone injections into the muscles beginning in the second trimester (16 to 20 weeks) and continuing through the 36th week of gestation. Some clinicians recommend this treatment for women with twin pregnancies who have had a spontaneous preterm birth, but this is controversial.
- For women (singleton or twin pregnancy) with midtrimester cervical shortening (defined as 20 millimeters or less before 24 weeks) and no prior spontaneous singleton preterm birth, the following is recommended: vaginal progesterone treatment through the 36th week. Options include a vaginal suppository, gel or tablet. Research shows that in women with a sonographically detected short cervix, progesterone treatment may be as effective as cerclage in singleton pregnancies.
Is progesterone supplementation indicated?
1. Singleton pregnancy, prior spontaneous singleton preterm birth, normal cervical length: Yes
2. Singleton pregnancy, prior spontaneous twin preterm birth, normal cervical length: Possibly
3. Singleton pregnancy, no prior spontaneous preterm birth, short cervix (≤20 mm): Yes
4. Multiple pregnancy (twins or triplets) without prior preterm birth, normal cervical length: No
5. Twins, prior preterm birth: Possibly
6. Twins, short cervix: Possibly
7. Preterm premature rupture of membranes: No
8. Positive fetal fibronectin test: No
9. Undelivered after an episode of preterm labor: Unclear
Although women with a history of preterm birth due to PPROM appear to benefit from progesterone, the treatment is not beneficial in women with PPROM in the current pregnancy.
Contraindications and Side Effects of Progesterone Therapy
Minor side effects of progesterone are related to the route of administration, and include injection site reactions and vaginal irritation or discharge. Oral progesterone can induce sleepiness, fatigue and headache. Progesterone is contraindicated when a woman has arterial disease, liver disease and undiagnosed vaginal bleeding.
Progesterone Use and Medical Malpractice
If a woman is at risk for preterm labor or delivery and / or having a short cervix, it is imperative for the physician to closely monitor the mother and baby and take every action to prevent preterm labor and its potentially devastating complications. Progesterone significantly reduces the risk of preterm labor in several instances. If a physician fails to diagnose a short cervix and / or take a thorough history of the pregnant woman, it is negligence. Failing to prescribe progesterone when it is indicated also may constitute negligence. If this negligence causes injury in the baby, it is medical malpractice.
Legal Help for Birth Injuries from Progesterone Misuse and Premature Birth
The award-winning birth injury attorneys at Reiter & Walsh ABC Law Centers have helped dozens of children affected by periventricular leukomalacia (PVL), hypoxic ischemic encephalopathy (HIE) and cerebral palsy. Our team has over a century of legal experience in birth injury litigation, and we’ve handled an array of cases involving premature birth injuries, HIE, cerebral palsy and medical mistakes related to pregnancy, labor, delivery, and neonatal care. Our birth injury attorneys are based in Detroit, Michigan, but we handle cases all over the U.S. Many of our clients have hailed from Michigan, Ohio, Texas, Wisconsin, Washington D.C., Pennsylvania, Tennessee, Arkansas, Mississippi, and other states. The Reiter & Walsh, P.C. birth trauma team has also handled FTCA (Federal Tort Claims Act) cases involving military medical malpractice and federally funded clinics.
If your child has a birth injury such as periventricular leukomalacia, hypoxic ischemic encephalopathy, seizures or cerebral palsy, contact Reiter & Walsh today at (888) 812-6009. Our award-winning birth injury attorneys are available 24/7 to speak with you, and there is no fee until we win your case. Contact us in any way you prefer:
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Video: Our Birth Injury Attorneys Discuss Premature Birth and Periventricular Leukomalacia (PVL)
In this video, birth injury attorney Jesse Reiter discusses how failure to prevent premature birth can cause a child to have birth injuries such as periventricular leukomalacia (PVL).
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